Showing posts with label General Medicine. Show all posts
Showing posts with label General Medicine. Show all posts

Obesity | Overweight

Obesity | Overweight

All about Obesity

obesity and overweight

Obesity Introduction

Obesity is widely regarded as a pandemic, with potentially disastrous complication for human health

Causes of Obesity

  1. Increase Energy Intake
    • Increase protein size
    • Increase snacking
    • Loss of regular meals
    • Increase energy food (mainly fat)
    • Increased affluence
  2. Decreasing Energy Expenditure
    • Increase car ownership
    • Decrease walking
    • Increase automation
    • Decrease manual labour
    • Decrease sports in school
    • Increase time spent on computer
    • Increase central heating
  3. Endocrine Factors
    • Hypothyroidism
    • Cushing's Syndrome
    • Insulinoma
    • Hypothalamic tumors / injury
  4. Medications
    • Atypical antipsychotics (eg. Olanzapine)
    • Sulphonylurease
    • Thiazolidinediones
    • Insulin
    • Corticosteroids
    • Sodium valproate
    • Beta blockers

Complications of Obesity

  1. Associated with Diabetes and Hypertension
    • Coronary heart disease
    • Stroke
    • Diabetes complications
  2. Associated with Liver Fat Accumulation
    • Non-alcoholic steatohepatitis
    • Cirrhosis
  3. Associated with Restricted Ventilation
    • Exertional dyspnoea
    • Obstructive sleep apnoea
    • Obesity hypoventilation syndrome
  4. Associated with Mechanical Effects of Weight
    • Urinary incontinence
    • Osteoarthritis
    • Varicose veins
  5. Associated with Increased Peripheral Steroid Interconversion in Adipose Tissue
    • Hormone dependent cancers (breast, uterus)
    • Polycyclic ovarian syndrome
    • Infertility
    • Hirsutism
  6. Others
    • Psychological morbidity (low self esteem, depression)
    • Socioeconomic disadvantages (low income)
    • Gallstones
    • Colorectal cancer
    • Skin infections (groin and submammary candidiasis)

Management of Obesity or Overweight

  1. Lifestyle Advice
    • Regular eating pattern
    • Maximising physical activity
    • More walking
    • Swimming
    • Avoidance of snacking
    • Regular meals
    • Substitution of sweets with artificial sweeteners
  2. Weight loss Diet
    • Low calorie diet
    • Vitamin supplementation
  3. Drugs
    • Orlistat
  4. Surgery
    • Bariatric Surgery
    • Cosmetic Surgical Procedure
    • Apronectomy: Removal of overhanging abdominal skin
  5. Treatment of additional Risk Factors: eg. smoking, excess alcohol consumption, diabetes mellitus, hypertension, obstructive sleep apnoea, hyperlipidaemia

Diabetic Ketoacidosis (DKA)

Diabetic Ketoacidosis

What is Diabetic Ketoacidosis?

sugar and insulin syringe for diabetes

Introduction

Diabetic Ketoacidosis is a medical emergency and remains a serious cause of morbidity, principally in people with type 1 diabetes

Risk Factors for Diabetic Ketoacidosis

  1. Type 1 Diabetes
  2. Cerebral oedema in children and adolescents
  3. Hypokalaemia
  4. Acute respiratory distress syndrome
  5. Acute myocardial infarction
  6. Sepsis
  7. Pneumonia

Pathogenesis of Diabetic Ketoacidosis

  1. Cardinal Biomechanical features
    • Hyperketonemia (>3 mmol/L)
    • Ketonnuria (>2 on standard urine sticks)
    • Hyperglycaemia (blood glucose >11 mmol/L or >200mg/dL)
    • Metabolic acidosis (venous bicarboate <15mmol/L and Venous pH <7.3)
  2. Hyperglycaemia causes profound osmotic diuresis leading to dehydration and electrolyte loss, particularly Potassium and Sodium
  3. Potassium loss is exacerbated by secondary hyperaldosteronism due to reduced renal perfusion
  4. Ketosis result from insulin deficiency exacerbated by elevated catecholamines and other stress hormones
  5. Due to more unmetabolized acidic ketones, it starts accumulating in blood
  6. Metabolic acidosis forces hydrogen ions into cells, displacing potassium ions

Clinical Feature of Diabetic Ketoacidosis

Symptoms of Diabetic Ketoacidosis

  1. Polyuria, Thirst
  2. Weight loss
  3. Weakness
  4. Nausea, Vomitting
  5. Leg cramps
  6. Blurred vision
  7. Abdominal pain

Signs of Diabetic Ketoacidosis

  1. Dehydration
  2. Hypotension (Postural or Supine)
  3. Cold extremities / Peripheral cyanosis
  4. Tachycardia
  5. Air hunger (Kussmaul breathing)
  6. Smell of Acetone
  7. Hypothermia
  8. Confusion / Drowsiness / Coma

Investigations for Diabetic Ketoacidosis

  1. Venous blood: Urea, Electrolytes, Bicarbonates
  2. Urine or Blood analysis for ketones
  3. ECG
  4. Infection screen
    • Full blood count
    • Blood and Urine culture
    • C-reactive protein
    • Chest X-ray

Treatment for Diabetic Ketoacidosis

  1. Insulin
    • A fixed rate IV infusion of 0.1U/kg body weight/hr is recommended
    • If IV not possible soluble insulin can be given by intramuscular injection with loading dose of 10-20 U, followed by 5 U hourly
    • Alternatively fast acting insulin analogue can be given hourly by subcutaneous injection with initial dose of 0.3 U/kg body weight, followed by 0.1 U/kg hourly
  2. Fluid Replacement
    • Rapid fluid replacement for first few hours is recommennded for adults
    • Caution is recommended in children and adolescent due to chances of developing cerebral oedema
  3. Potassium
    • Careful monitoring of potassium is essential to prevent hyperkalaemia or hypokalaemia
    • Potassium replacement usually not recommended in initial treatment because pre-renal failure maybe present secondary to dehydration
    • Cardiac rhythm should be monitored in severe DKA due to risk of electrolyte induced cardiac arrhythmia
  4. Bicarbonate: Adequate fluid and insulin replacement should resolve acidosis

Epilepsy | Seizure

Epilepsy and Seizure

What is Epilepsy?

epilepsy seizure stroke

Introduction

Epilepsy is the tendency to have unprovoked seizures

Definition of Seizure

Seizure can be defined as the occurrence of signs and symptoms due to abnormal, excessive or synchronous neuronal activity in the brain

Triggering Factors of Seizures

  1. Sleep deprivation
  2. Missed dose of anti-epileptic drugs
  3. Alcohol withdrawal syndromes
  4. Recreational drug misuse
  5. Physical and mental exhaustion
  6. Flickering lights (TV and Computer screens)
  7. Intercurrent infections and metabolic disturbance
  8. Loud music, noise, hot baths

Classification of Seizures

  1. Generalized Seizure
    • Tonic-Clonic Seizure
    • Absence Seizures - Typical / Atypical / Absence with special features
    • Myoclonic - Myoclonic / Myoclonic atonic / Myoclonic tonic
    • Clonic
    • Tonic
    • Atonic
    • Myeloid Absence Seizures
    • Eyelid Myoclonia
  2. Focal Seizures
    • Without impairment of consciousness or awareness
    • With impairment of consciousness or awareness
    • Evolving to a bilateral, convulsive seizure - Tonic / Clonic / Tonic-Clonic
  3. Unknown Seizure
    • Epileptic spasm

Causes of Focal Seizures

A) Idiopathic

  1. Benign Rolandic Epilepsy of childhood
  2. Benign Occipital Epilepsy of childhood

B) Focal Structural Lesions

  1. Genetic
    • Tuberous Sclerosis
    • Autosomal dominant frontal lobe epilepsy
    • Autosomal dominant partial epilepsy with auditory features
    • Von Hippel-Lindau disease
    • Neurofibromatosis
    • Cerebral migration abnormalities
  2. Infantile Hemiplegia
  3. Dysembryonic
    • Cortical dysgenesis
    • Sturge-Weber Syndrome
  4. Mesial Temporal sclerosis
  5. Cerebrovascular disease
    • Intracerebral haemorrhage
    • Cerebral infarction
    • Arteriovenous Malformation
    • Cavernous Haemangioma
  6. Tumours (Primary and Secondary)
  7. Trauma
  8. Infective
    • Cerebral abscess
    • Toxoplasmosis
    • Cysticercosis
    • Tuberculoma
    • Subdural empyema
    • Encephalitis
    • HIV
  9. Inflammatory
    • Sarcoidosis
    • Vasculitis

Causes of Generalized Tonic-Clonic Seizures

  1. Generalisation from Focal Seizure
  2. Genetic
    • Inborn errors of metabolism
    • Storage diseases
    • Phakomatosis
  3. Cerebral birth injury
  4. Hydrocephalus
  5. Cerebral anoxia
  6. Drugs
    • Antibiotics: Penicillin, Isoniazid, Metronidazole
    • Antimalarials: Chloroquine, Mefloquine
    • Ciclosporin
    • Cardiac Anti-arrhythmics: Lidocaine, Disopyramide
    • Psychotropic agents: Phenothiazines, Tricyclic anti-depressants, Lithium
    • Amphetamines withdrawal
  7. Alcohol
  8. Toxins
    • Organophosphate
    • Heavy metals (lead, tin)
  9. Metabolic disease
    • Hypocalcaemia
    • Hypoglycaemia
    • Hypomagnesaemia
    • Liver failure
    • Renal failure
  10. Infective
    • Post-infectious encephalopathy
    • Meningitis
  11. Inflammatory
    • Multiple sclerosis
    • SLE
  12. Diffuse degenerative disease
  13. Alzheimer's Disease
  14. Creutzfeldt-Jakob disease

Investigations of Epilepsy

  1. ECG
    • Standard ECG
    • Sleep ECG
    • ECG with special electrodes
  2. CT
  3. MRI
  4. For Metabolic disorder
    • Urea and electrocytes
    • Blood Glucose
    • Serum calcium, Magnesium
  5. For Inflammatory or Infective disorder
    • Full Blood count
    • Erythrocyte Sedimentation Rate
    • C-reactive protein
    • Chest X-ray
    • Serology for syphilis, HIV, Collagen disease
  6. CSF Examination
  7. Ambulatory ECG
  8. Videotelemetry

Management of Epilepsy

  1. First aid Management for Seizure
    • Move person away from danger (fire, water, machinery, furniture)
    • After convulsion ceases turn person into recovery position (semi-prone)
    • Ensure airway is clear or insert anything in mouth
    • If convulsions continue for more than 5 mins or recur without person regaining consciousness, summons urgent medical attention
    • Do not leave the person alone until fully recovered
  2. Immediate Care
  3. Lifestyle Advice
    • Avoid triggering factors
    • Only shallow bath
    • Prolong cyclone journey is avoided
    • Activities requiring prolonged proximity to water (swimming, fishing, boating) should be carried out in company with someone
  4. Anticonvulsant / Anti-epileptic Therapy
  5. Monitoring Therapy
  6. Epilepsy Thearpy
  7. Withdrawal of Anticolvusant Therapy

Diabetes Mellitus

Diabetes Mellitus

All about Diabetes Mellitus

diabetes checking machine

Introduction

Diabetes Mellitus is a clinical syndrome characterized by an increase in plasma blood glucose level, which is also called as Hyperglycemia

Etiological Classification of Diabetes Mellitus

  1. Type 1 Diabetes (Insulin Dependent Diabetes Meliitus)
    • Immune mediated
    • Idiopathic
  2. Type 2 Diabetes (Insulin Independent Diabetes Mellitus)
  3. Other Specific Types
    • Genetic defect of beta cell function
    • Genetic defect of insulin action
    • Pancreatic disease
    • Excess endogenous production of hormone antagonist to insulin
    • Drug induced
    • Uncommon form of immune mediated diabetes
    • Associated with genetic syndromes
  4. Gestational Diabetes

Symptoms of Hyperglycemia

  1. Thirst
  2. Dry Mouth
  3. Nocturia
  4. Unusual weight loss
  5. Tiredness, Fatigue, Lethargy
  6. Blurring of vision
  7. Nausea
  8. Headache
  9. Hyperphagia - Predilection for sweet foods
  10. Mood change, irritability
  11. Difficulty in concentrating
  12. Apathy
  13. Genital candidiasis - pruritus vulve, balanitis

Diagnosis of Diabetes and Pre-Diabetes

  1. Plasma Glucose level
  2. Plasma Urea, Creatinine, Electrolytes
  3. Liver Function Test
  4. Thyroid Function Test
  5. Urine test for Ketones, protein or microalbuminuria

Management of Diabetes Mellitus

  1. Dietary and lifestyle modification
    • Regular physical activity
    • Healthy diet
    • Limit the sodium intake (less than 6 gm per day)
    • Reducing alcohol consumption
    • Stoppage of smoking
  2. Oral Anti-diabetic drugs
    • Biguanide - Metformin
    • Sulphonylurease
    • Alpha Glucosidase inhibitor
    • Thiazolidinediones
    • Sodium and Glucose Transporter 2 (SGLT2) inhibitor
  3. Injectable Insulin therapy

Complications of Diabetes Mellitus

A) Microvascular / Neuropathic

  1. Retinopathy - Cataract, Impaired vision
  2. Nephropathy - Renal failure
  3. Peripheral Neuropathy - Sensory loss, Pain, Motor weakness
  4. Autonomic Neuropathy - GIT problems, Postural hypotension
  5. Foot Disease - Ulceration, Arthropathy

B) Macrovascular

  1. Coronary Circulation - Myocardial Ischaemia / Infarction
  2. Cerebral Circulation - Transient Ischaemic Attack, Stroke
  3. Peripheral Circulation - Claudication, Ischaemia

Hypertension

Hypertension

All about Hypertension

blood pressure measurement

Introduction

Hypertension is the level of blood pressure (BP) at which the benefits of treatment outweigh the costs and hazards

Types of Hypertension

Staging of Hypertension Systolic BP Diastolic BP
Prehypertension 120 - 139 mmHg 80 - 89 mmHg
Stage 1 Hypertension 140 - 159 mmHg 90 - 99 mmHg
Stage 2 Hypertension 160 - 179 mmHg 100 - 109 mmHg
Stage 3 Hypertension >180 mmHg >110 mmHg

Causes of Secondary Hypertension

  1. Alcohol
  2. Obesity
  3. Renal Disease
    • Parenchymal Renal Disease - Glomerulonephritis
    • Renal Vascular Disease
    • Polycystic Kidney Disease (PKD)
  4. Endocrine Disease
    • Pheochromocytoma
    • Cushing's Syndrome
    • Thyrotoxicosis
    • Primary Hyperaldosteronism (Conn's Syndrome)
    • Hyperparathyroidism
    • Primary Hyperthyroidism
    • Acromegaly
    • Liddle's Syndrome
    • Congenital Adrenal Hyperplasia (CAH)
  5. Drugs
    • Oral Contraceptives containing oestrogen
    • Anabolic Steroids
    • Corticosteroids
    • NSAIDs
    • Carbenoxolone
    • Sympathomimetic Agent
    • Coarctation of Aorta

Symptoms of Hypertensive Patients

  1. Severe headache
  2. Nosebleed
  3. Fatigue or confusion
  4. Vision problem
  5. Chest pain
  6. Difficulty in breathing
  7. Irregular heartbeat
  8. Blood in the urine
  9. Pounding in your chest, neck or ears
  10. Dizziness
  11. Nervousness
  12. Sweating
  13. Trouble sleeping
  14. Facial flushing
  15. Blood spots in eyes

Signs of Hypertension

  1. Radiofemoral Delay (Coarctation of Aorta)
  2. Enlarged Kidneys (Polycystic Kidney Disease)
  3. Abdominal Bruits (Renal Artery Stenosis)
  4. Characteristic Facies (Cushing's Syndrome)
  5. Blood vesels Atherosclerosis
    • Larger arteries (more than 1 mm in diameter): Internal elastic lamina is thickened, Smooth muscle is hypertrophied and Fibrous tissue is deposited. So vessels dilates and becomes torus with less compliant walls
    • Smaller arteries (less than 1 mm in diameter): Hyaline arteriosclerosis in wall, narrowing of lumen
    • Widespread atheroma develop and may lead to coronary and cerebrovascular diseases
    • These vascular changes increase peripheral vascular resistance which aggravates hypertension. Reduced renal blood flow activates Renin-Angiotensin-Aldosterone-Axis
  6. Central Nervous System
    • Cerebral Haemorrhage and Cerebral Infarction leads to Stroke Carotid Atheroma Subarachnoid Haemorrhage Hypertensive Encephalopathy
  7. Retina
    • Cotton wool exudates and Microaneurysm
    • Retinal ischaemia and infarction
    • Central retinal vein thrombosis
  8. Heart
    • Left ventricular hypertrophy
    • Atrial fibrillation
    • Left ventricular failure
  9. Kidneys
    • Proteinuria
    • Renal failure

Diagnosis of Hypertensive Patients

  1. Accurate BP measurement
  2. Identify contributing factors and underlying causes
  3. Detect any complications eg.target organ damage (blood vessels, CVS, CNS, Retina, Kidney)

Investigations of Hypertensive Patients

  1. Urinalysis of blood, protein and glucose
  2. Blood, urea, electrolytes and creatinine
  3. Blood Glucose
  4. Serum total and HDL Cholesterol
  5. Thyroid Function Tests
  6. 12 - Lead ECG

Management of Hypertensive Patients

  1. Quantification of Cardiovascular Risk
  2. Threshold for Intervention
  3. Treatment Targets
  4. Non-drug Therapy
    • Correcting Obesity
    • Reducing Alcohol intake
    • Quitting Smoking
    • Restricting Salt intake
    • Regular Physical Exercise
    • Increasing consumption
  5. Antihypertensive Drugs
    • Thiazide and other Diuretics
    • ACE Inhibitors
    • Beta blockers
    • Labetalol, Carvedilol
  6. Emergency Treatment for Malignant Hypertension
  7. Adjuvant Drug Therapy
    • Antiplatelet Therapy - Aspirin
    • Statins

Electrocardiogram (ECG) / Electrocardiography

Electrocardiogram (ECG) / Electrocardiography

Basics Of ECG..

electrocardiograph

Introduction

  • Electrocardiogram records the graphical representation of electrical signals from the heart to rule out different heart conditions
  • Electrocardiography is a technique by which electrical activities of the heart is studied
  • Electrocardiograph (ECG Machine) is the instrument by which electrical activities of the heart is recorded
  • Willem Einthoven is called the Father of ECG

Electrocardiographic (ECG) Grid

  1. Duration:
    • Duration of different waves denoted by Vertical lines
    • Interval between 2 thick lines (5 mm) = 0.2 second
    • Interval between 2 thin lines (1 mm) = 0.04 second
  2. Amplitude:
    • Amplitude of ECG wave denoted by Horizontal lines
    • Interval between 2 thick lines (5 mm) = 0.5 mV
    • Interval between 2 thin lines (1 mm) = 0.1 mV
  3. Speed of the Paper: 25 mm per second (normally) or 50 mm per second (high heart rate)

Waves of Electrocardiogram

waves of electrocardiogram
  1. P Wave
    • P wave is the positive wave and 1st wave in ECG
    • It is produced due to the Atrial Depolarization
    • Duration - 0.1 second
    • Amplitude - 0.1 to 0.12 mV
  2. QRS Complex
    • It is also called Initial Ventricular Complex
    • Q wave is small negative wave, continued as tall R wave
    • R wave is positive wave, followed by small negative S wave
    • QRS Complex is produced due to Ventricular Depolarization
    • Duration - 0.08 to 0.10 seconds
    • Amplitude
      • Q wave: 0.1 to 0.2 mV
      • R wave: 1 mV
      • S wave: 0.4 mV
  3. T Wave
    • T wave is the positive wave and final ventricular complex
    • It is produced due to Ventricular Repolarization
    • Duration - 0.2 second
    • Amplitude - 0.3 mV
  4. U Wave
    • It is rare and insignificant wave of ECG
    • It is produced due to Repolarization of papillary muscles

Interval and Segments of ECG

  1. P - R Interval
    • Interval between onset of P wave and onset of Q wave
    • Signifies Atrial Depolarization and conduction of impulses through AV nodes
    • Duration - 0.18 second
  2. Q - T Interval
    • Interval between onset of Q wave and end of T wave
    • Signifies electrical activity in Ventricles
    • Duration - 0.4 to 0.42 seconds
  3. S - T Interval
    • Interval between end of S wave and onset of T wave
    • It is Isoelectric
    • Duration - 0.08 second
  4. R - R Interval
    • Interval between 2 consecutive R waves
    • Signifies the duration of 1 Cardiac CycleInterval between 2 consecutive R waves

ECG Leads

einthoven traingle of ECG
  1. Surface of body is connected to the ECG machine by means of 2 electrodes called ECG lead
  2. ECG leads are of 2 types: Bipolar and Unipolar leads
  3. Einthoven's Triangle: Electrodes are fixed on the limbs (right arm, left arm, left leg) and the heart is in the center of an imaginary equilateral triangle drawn by connecting the roots of these 3 limbs
  4. Bipolar Leads known as standard limb leads where 2 limbs are connected, standard limbs are of 3 following types
    • Lead 1 is obtained by connecting right arm and left arm, where right arm is connected to negative terminal and left arm is connected to positive terminal
    • Lead 2 is obtained by connecting right arm and left leg, where right arm is connected to negative terminal and left leg is connected to positive terminal
    • Lead 3 is obtained by connecting left arm and left leg, where left arm is connected to negative terminal and left leg is connected to positive terminal
  5. Unipolar Leads are of 2 types
    • Unipolar Limb Lead
    • Unipolar Chest Lead
Subscribe to: Posts (Atom)